Q&A with consultant orthopaedic surgeon Tony Kochhar

Consultant orthopaedic surgeon Tony Kochhar joined us in April 2011 to answer your questions about RSI and musculo-skeletal problems. You had questions about 'baby wrist', which is associated with use of breast pumps, bottle feeding and carrying newborns, along with 'back-to-work wrist' where acute RSI develops rapidly after the end of maternity leave. Tony also had advice about stretching, knee injuries and ganglions.

Tony trained at The Royal National Orthopaedic Hospital, London, and has worked with some of the best surgeons in the world, notably in New York and at the renowned Alps Surgery Institute in Annecy, France. He practises at London Bridge Hospital, and in Kent, and has set up what is believed to be the country's first clinic dedicated to treating repetitive strain injuries.

Q. josephsmom: I have had acute RSI for about three years now. It started at work, and typing, lifting (even a small baby) and writing all cause pain in both arms. I've gone back to work now (I'm computer programmer) and it is as bad as ever. I have seen numerous medical practitioners: doctors, physios, osteopaths, rheumatologists etc. Nothing seems to work. Even prolonged time off work would be no guarantee of improvement. It's beginning to seem like change of career might be unavoidable. Any words of advice?

A. Tony: No, no, no! I am so sorry to hear that changing career has become a possibility. These are conditions that if accurately diagnosed can be completely cured with the right therapy.
I am sure you have been through these in isolation but it is all about being under the care of a specialist who can orchestrate a combination of the right therapies.

There are so many different types of physio and for RSI it is really the manual-type therapy that is the most useful in the early stages. Further down the line, patients need stretching and strengthening exercises.

I would suggest you don't give up. To try to come to an accurate diagnosis, ask yourself: what is irritated/damaged and how badly? And what makes my condition worse? What individual adaptations/treatments have made it better at least in part? Once those three points are worked out, then it's all about finding the right combination and persevering.

Q. hobnob57: I got an acute bout of tenosynovitis in my wrist while on maternity leave, probably from steering the pram one-handed whilst pushing my three-year-old up hills on her bike. Since then I have returned to work and have found it has come back, particularly when I am using the laptop. Is there anything I can do about it, other than to abstain from using computers (which I can't do really as I need to check and respond to work emails on my days off and I use computers at work as part of teaching)?

A. Tony: The onset of tenosynovitis, when we start to perform quite strenuous activities which we have not previously had to do, is quite common. I think the most encouraging thing is that by and large your symptoms seem to have settled. The aim is to reduce the provocative activity and to reduce the inflammation. Secondly, we need to strengthen those tissues (tendons and muscles) so that they are used to these new movements and loads. It does seem clear that the new activity (ie pushing the pram) brought on this inflammatory process and that your return to computer work continues to aggravate these tissues.

There are a few measures that I would recommend.

Try a wrist bar when typing. If this does not help then a wrist splint may help. I would however only use this when typing or when at work.

I would try a course of anti-inflammatory tablets for perhaps two weeks (ibuprofen 400mg twice a day – please ensure that there is no contraindication to you taking these tablets and if in doubt see your GP, especially if you are breastfeeding). I'm sure you might be thinking, "I tried Ibuprofen and it doesn't work..." Try a full course as suggested, it will have an effect and, coupled with the other measures, should lead to some relief.

Have a course of physiotherapy. You would need to see somebody who is a specialist in upper-limb physio. They are not commonly found, so I would ask the physio you choose what specific training they have in the treatment of upper limb conditions and in manual therapy (the mainstay form of physio for these conditions). The course should consist of manual therapy to release the scarred or irritated tissues, stretching exercises, then on to strengthening exercises. In addition, you may need ultrasound treatment, or may have to rest your wrist in a wrist splint, which the physio would fit.

If this doesn't settle, see a specialist upper limb orthopaedic surgeon like myself - you may need further assessment and/or investigations (perhaps an MRI).

Please let me know how you get on. I see a lot of similar cases and this should settle down within six weeks or so.

Q.buzzy1: I am interested to hear more about developing acute RSI very quickly upon returning to work after maternity leave. I started work part-time in January this year, after 15 months maternity leave, and have since noticed a tingling and occasionally throbbing pain, plus numbness, around the tendons at the back of my right hand. I also find my right hand is much weaker and feel pain after ironing or opening a tight lid, for instance. I have suffered from RSI in the past from using a mouse, so I switched to a roller mouse that worked well in the past. However, this hasn't help much since my return to work. What can I do to alleviate this pain and bring back the strength in my right hand?

A. Tony: Firstly, I would discuss with your health and safety representative at work getting a workplace assessment done. As well as a roller mouse, you may require an ergonomic keyboard or a wrist-pad to sit in front of the keyboard so that your wrist remains at the correct position.

As with my response to PickleFish (below), the tingling and sensory disturbance suggests irritation of the nerves. This may be activity-induced. I would suggest you see a physiotherapist or orthopaedic surgeon (who specialises in upper limb problems) to get on top of this RSI. In my experience, a short period of splinting followed by some specialist therapy often results in an excellent recovery within about six to eight weeks.

Q. nojobtoosmall: Wrist injuries at work? My physio reminded me how all touch typists used to be trained. They didn't have arms on office chairs, but typed with elbows always touching their lower ribs. I was advised to work my mouse on a small mouse-mat with a wrist rest, while keeping my elbow against my body and the mat as near to me as possible. No more reaching out and away across the desk with my mouse hand and arm. Result? Problem soon vanished.

A. Tony: I completely agree. We sit at our desks for hours and hours in the day and even the slightest adjustment can be beneficial in these conditions. For example, I used to have irritation of my rotator cuff in my right shoulder and I noticed that it would become extremely sore when I used a mouse. This was because my arm was always reaching outwards (which irritated the rotator cuff). This completely went as soon as I moved my mouse mat to in front of my keyboard.

Q. Umleila: I get RSI in my right hand that spreads up to my neck and causes headaches, and also into my shoulder, down to my back and even my right hip and leg when it is at its worst (I type for a living). Often it feels like I have a hot knot under my right shoulder blade. I use pain-killing cream on it when it's at its worst, but I am concerned because I have heard a theory that constant inflammation of an area can predispose one to cancer of that area. Is that right?

A. Tony: The symptoms you describe sound very much like they involve your neck, shoulderblade and spine. This is clearly also irritating your pelvis. I would recommend an assessment of your workspace, particularly with regard to your chair and screen height. I would also suggest some physiotherapy.

With regards to the shoulderblade pain, this may relate to a problem with a trapped nerve in your neck causing this classical periscapular pain. I would suggest an assessment by your GP. He or she might refer you to a spinal specialist or a pain specialist. To be honest, I have never heard of the theory you have mentioned. There is nothing in current medical practice that relates to this theory.

Q. mousymouse: I had a ganglion in my wrist when I was a teenager and it was treated with a brace and steroid injections. The pain was so bad that I couldn't even ride a bike as every bump hurt a lot, but after a while it went away. Now I'm in my 30s, have had a second baby who I have to carry a lot, and my left wrist hurts, plus my day job requires me to type a lot, but no heavy lifting.) I try to use a backpack more often so that I don't have to carry my bag with my hands anymore, but picking up my child is unavoidable. Could I try to use the brace again for a couple of hours a day (if it still fits)?

A. Tony: While most wrist splints are essentially the same, I wouldn't immediately recommend that you just pop on the splint. It may not be the case that your previous ganglion is associated with your current wrist pain. My impression from your posting is that your wrist pain is aggravated by typing, and lifting and carrying your second child. I would certainly have an assessment by a physiotherapist or an upper limb orthopedic surgeon.

"One of the fundamental reasons why these conditions are so difficult to treat is that the ability for a tissue to heal is related to its blood supply. The tissues involved (tendons, ligaments, tendon sheaths and nerves) have a poor blood supply."

Again, it may be due to wrist tendonitis. The fundamentals of treatment include rest to allow the tissues to heal, manual therapy to help release the irritated tissues and to stimulate them to recover and stretching/strengthening so that they can return to normal function/adapt to their new requirements.

One of the fundamental reasons why these conditions are so difficult to treat is that the ability for a tissue to heal is related to its blood supply. By and large, the tissues involved (tendons, ligaments, tendon sheaths and nerves) have a poor blood supply.

Q. washnomore: I have a ganglion on my wrist and it aches and aches, enough to wake me at night sometimes. The GP offered to hit me with her Bible. I use ibuprofen gel if it's really bad and try to avoid one-handed pram-pushing (easier said than done), and avoid using the mouse and keyboard too much. The only other thing I was offered was to have it drained but it sounds pointless to me - draining a bursa surely affords very temporary relief as it will refill and it doesn't really address the problem. What are your thoughts on that?

Also, when a physio offered me ultrasound (for an unrelated condition) I asked her what its mechanism of action was. She told me nobody knew, and that there was no evidence of a beneficial outcome with its use. I declined to have any, but could you tell us more about that?

A. Tony: Yes, you're absolutely right. Draining a ganglion is usually a temporary measure. The reason why it is offered is that it may work permanently (10-20%) and it is very low risk. The definitive treatment is to have it surgically excised. This is clearly a surgical operation but can be done under local anaesthetic. However, there is still a risk of it recurring (approximately 20%) and naturally there are risks associated with this procedure. In my practice, if a ganglion is causing pain and stopping you from performing your normal activities, having discussed all options with the patient, I would recommend to have a surgical excision.

As for your ultrasound question, a basic explanation is that it has been shown to speed up the rate of healing and also to improve the quality of the repair. There are thermal and non-thermal effects from the ultrasound, so it would depend on what settings the therapist chose to use (eg pulsed or continuous) based on what they were trying to achieve with their treatment (eg for scar tissue and stretching, you may choose to apply a heating effect using a continuous mode on the tissues prior to stretching).

Q. carsem: I've had wrist pain for over four months now, and have already had already physio treatments and ultrasound heat. I use Deep Heat from time to time as well to relieve the pain. I am doing different exercises for 10 minutes, twice a day, and have reduced my mouse use already, but the pain is still there. What else can I do?

A. Tony: I think the first thing to do is to locate where in the wrist you are experiencing the pain. Pain is the body's indicator that something is not working as it should do, so the location is a vital key in identifying which structures are in trouble. The next thing to do is to sit down and make a list of which activities cause pain, when you get the pain (day or night, at the end of the day or in the morning) and if there are any other features (pins and needles, stiffness, weakness). Once you have this information, I think you will have the first steps to understanding what is causing the wrist pain and how to settle it down. Has your physio gone through this with you and have they given you a diagnosis/treatment plan or schedule?

"Pain is the body's indicator that something is not working as it should do, so the location is a vital key in identifying which structures are in trouble. "

Q. Kalypso: I haven't actually been seen my GP about 'baby wrist', but I'm fairly confident that's what I have. My son is now 13 months old and my wrist pain has been bothering me since he was about three months old. It did initially affect both wrists, but now it's mainly the right one. The reason I haven't done anything about it is that for much of the time I don't notice any pain. However, sometimes when I am holding my son in a certain way - particularly when lowering him onto his changing mat - my right wrist just 'buckles'. It feels like something is 'twanging' or 'snapping' on the inner side of my wrist and sometimes the area looks a bit swollen. I tried wearing a wrist support, but found it made the pain worse (the pressure was really uncomfortable).

My question is, is this something that is ever likely to resolve by itself as my son grows older and needs less carrying, thus giving my wrist a chance to heal? Or is it likely I am going to need physio to get my wrist back to normal?

A. Tony: This does sound like 'baby wrist'. It usually affects the thumb side of the wrist rather than the little finger side, but it depends on which movement is aggravating which tendon. By the time your son becomes more independent, this may have become a chronic, severe RSI. The most important thing is to get on top of this problem as quickly as possible rather than letting it become chronic. Off-the-shelf splints can make your symptoms worse and you may need to see a specialist physio, called a hand therapist, who can make a customised splint (thermoplastic) that fits you exactly. Rest, physiotherapy and possibly an injection may also help.

Q. herbietea: I have had SPD (symphysis pubis dysfunction) for 15 years. I was on and off crutches for the first 11 years, but have had to use them permanently for the past four years. I have to put most of my weight through my arms/wrists/hands.

I bought some crutches with soft, ergonomic hand grips but my wrists and hands are so painful from using them all the time. I have had ultrasound treatments, deep-tissue massage and was advised to wear a splint, but I can't hold my crutches then, so can't walk. Have you any ideas about what I can do to relieve my wrist pain?

A. Tony: SPD is a problem that affects many people post-partum. The hormone release in the last trimester, which allows the pubic ligaments to loosen so that your baby can be delivered, can lead to problems in the post-natal stage. This tends to be a temporary problem and is usually treated with specialist obstetric physiotherapy and simple anti-inflammatories. It is usually dealt with by obstetricians.

I have checked with a few obstetric colleagues and they have only very rarely heard of such a long-standing problem with SPD. My first point is to please have this reassessed, to make sure this is the right diagnosis.

With regards to your wrist pain, it does seem clear that your persistent use of crutches are putting an excessive load on your wrist joints and the surrounding tendons. There are some ergonomic handles for crutches as well as neoprene grips that can reduce the impact. You may want to try these, but I think the treatment you have had so far should certainly help although it may take some time.

Q. CMOTDibbler: I lost the use of my left hand last year in an accident. Of course, this has left me using my right hand for everything, including picking up my four-year-old. And I'm getting a nice dose of RSI in that arm now. I'm wearing a splint at night (well, two as I wear a custom thermoplastic on the left side), but is there anything else I can do?

A. Tony: I completely understand it is essential we get your one fully working hand back to normal. Splinting allows tissues to rest, so a night splint can be quite useful. However, splinting is only a part of the combination of therapies/treatments you might require. Furthermore, wearing it only at night will not limit the amount of aggravation caused by the provocative daytime activities.

Once again I think we need to accurately define which tissues are aggravated, which activities are causing this and therefore what therapies should be used in combination to cure this. I think you will need further assessment by either a physio or a medical specialist and very possibly further investigations, perhaps x-rays, an ultrasound scan and/or an MRI scan (depending on the findings of the assessment). Whoever you see must come to a definitive diagnosis; clearly, if they don't know what's broken how can they fix it?

Q. PickleFish: How can I avoid wrist pain (and shoulder/neck pain) from playing musical instruments, such as the violin, piano and harp? I have small hands that often have to stretch in unusual positions, plus I don't know how to relax my neck, shoulders etc when I am playing. I know that I'm probbaly tense, but I have no control over actually relaxing those muscles voluntarily, it seems. When I've been playing for more than a few minutes, I end up with lots of pain - and it's particularly bad when I'm going through a bout of RSI pain from typing; I have ways to adjust the typing, but can't seem to find equivalent ways to help with the music. I get pain in my fingers/thumbs, and in my fingertips (sometimes like touching something hot), as well as sore wrists, and it can get hard to move/rotate my wrist very far without some pain.

A. Tony: Stretching, stretching and stretching is the key! My wife works in HR in the City. When she started to develop neck pain and pain over the back of her shoulder (periscapular pain), I immediately returned the jewellery I was going to buy her for her birthday and instead bought a book called Stretching by a chap called Bob Anderson. It's been in print for many years and still holds the key for the prevention of many musculoskeletal problems (trust me, I'm not on commission – it's just an excellent book).

One final note – the hot sensation suggests there might be some irritation of the nerves (eg carpal tunnel syndrome). I would see a specialist to have this checked out.

"Weight plays a major part in both knee pain and the development of knee arthritis. On a simple level, if you weigh more, more forces go through the knee."

Q. Mmelindt: This is not specifically an RSI problem, but something to do with my knees. The first time I had problems with my knees was shortly before the birth of my second child, presumably because of the excess weight I was carrying. It got better for a while then I had a nasty fall when using rollerblades (without protection, idiot that I am) and they were sore for months. That was a few years ago and they are OK, unless I put on a bit of weight, which makes them hurt again.

I recently took up golf and they have started aching again. On the advice of the trainer, I have started doing gentle exercises to strengthen the muscles around the knees (I have not been doing much sport over the winter). Is there anything that you could advise that would help, other than this?

A. Tony: I think your trainer's advice is sound in the first instance. You have obviously overloaded your knees (at the end of the day, the more weight you carry the more load that goes through the knees). Rollerblading has almost certainly aggravated this as you have to continuously keep your knees flexed while you skate. This adds quite significant loads to the knee joint and to the kneecap.

Golf is not helping either. This is most likely because you have to keep walking reasonably long distances on uneven ground. In the first instance, I would go and see a physiotherapist just for a few sessions to learn some specific exercises that you can do on your own to stabilise the knees. If this does not settle them down, I would perhaps go and see your GP for a further assessment and also some x-rays.

Q. aristocat: I have a knee problem too, and was diagnosed with arthritis in one knee. It was particularly bad when I used to operate a pedal at work. I always assumed this began as RSI. I have had physio, then last year my GP suggested I try to lose weight to prevent a future operation. I took his advice to heart and I have lost four stone. My knee is much improved and I just wanted to ask, can losing weight really help that much? Or is it just a coincidence?

A. Tony: Yes, weight plays a major part in both knee pain and the development of knee arthritis. As before, on a simple level, if you weigh more, more forces go through the knee. It is actually much more complicated than that - as an example, the forces across the kneecap on certain activities increase up to seven times bodyweight, so a small drop in weight can be extremely beneficial.

Q. Orienteer: Do you have any advice for curing my chronic trochanteric bursitis? Cortisone doesn't work. I've spent over two years committing to stretching and gluteal muscle strengthening, but I'm not seeing any improvement yet.

A. Tony: This should have settled by now. A bursa is merely a bag of tissue which fills up with fluid to protect bony prominences. Sometimes the inflammation can be persistent. I would confirm the diagnosis with an MRI. Treatment options beyond what you have already had would include an ultrasound-guided steroid injection (to make sure it's in the right place), or surgical excision.

Q. lissielou: I was diagnosed with Tietze's Syndrome two years ago. I have got progressively worse with every rib swollen and dislodged now at the sternum and at the back. I am in constant pain and have lost a lot of grip in my right hand, I get numbness down my right side and have started to develop bony lumps on the bones now. Does this sound normal? Is there anything else I can do (aside from taking anti-inflammatories and painkillers which I'm already doing)?

A. Tony: I'm sorry to hear you're suffering. I would definitely see an orthopaedic surgeon for this. In its mild form, Tietze's syndrome is merely irritation of the small joints as the ribs join the breastplate. This is clearly much more severe. I think you certainly need further investigation with some x-rays and maybe a CT or MRI in the first instance.

"All therapies that are based around correct posture, breathing and core strength have been shown over many years to help with musculoskeletal problems. It is the bedrock of treatment of these conditions. "

Q. mummyfluffbrain: I have suffered with RSI and other muscular skeletal problems off and on for the past nine years, principally caused by working at a desk but exacerbated by carrying children.

The only treatment offered to me by the NHS has been four physiotherapy ultrasound sessions which have achieved nothing. As my condition can be quite debilitating, I have had no choice but to fund my own treatment and after a lot of expensive trial and error, I have found that a combination of the Alexander Technique and osteopathy works best to relieve my problems.

Given our increasing reliance on technology at work and home, RSI and other muscular skeletal problems are on the increase. So why is there not more widespread understanding and diagnosis of the problem and funding of appropriate treatments?

A. Tony: To be quite frank, this is why I have just set up the London RSI Clinic. It is not just the NHS. Even in the private sector, patients tend to be passed from pillar to post without any support or guidance. There are big gaps between referrals and often patients have expensive treatments which end up never working. Our approach is a multidisciplinary team. There is no duplication of referrals and no wasted time at all.

With regards to osteopathy, this is usually extremely beneficial as one component of therapy. The reason for this is manual-type therapy (manipulations, deep friction massage) can help release the tethered tissues and nerves. All therapies that are based around correct posture, breathing and core strength have been shown over many years to help with musculoskeletal problems. It is the bedrock of treatment of these conditions.

DISCLAIMER: All information and advice is provided as a source of general guidance only and should not replace the advice of your doctor or any other individual in the health care profession. If you have any concerns about your symptoms please see your GP or call NHS Direct.